Healthcare Provider Details

I. General information

NPI: 1912216847
Provider Name (Legal Business Name): JOEL C DYKSTRA PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2010
Last Update Date: 09/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9669 KENTON AVE
SKOKIE IL
60076-1266
US

IV. Provider business mailing address

1821 GRANT ST
EVANSTON IL
60201-2534
US

V. Phone/Fax

Practice location:
  • Phone: 847-933-3810
  • Fax:
Mailing address:
  • Phone: 847-492-8107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number070.008745
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: